tn board of nursing disciplinary actions

Please include your name, title/position, organization name, office phone and email in your request. Plymouth Meeting, PA 19462. During the investigation, it was never determined whether other nurses would talk to an orientee while pulling medications from an ADC. Nurses criminal trial is scheduled to begin. Getting to Know Your Licensing Board: the North Carolina Board of Nursing at a Glance; What Nurses need to know about Informatics, Social Media, and Security! Nurse failed to document vecuronium administration to the patient in the EHR. RaDondas immediate verbal disclosure to the team treating this patient far exceeded any benefit that would have been available through documentation. Consequences range from moderate to severe, including permanent license revocation and significant fines: In certain areas, such as alleged chart falsification or chart illegibility, the Tennessee Board of Nursing presumes the nursing professional acted with intent. By the time she arrived back in the intensive care unit (ICU), she learned of her error and immediately reported it and completed an event report. Professional boards must publish disciplinary license action each year by month per Tennessee Code Annotated, Section 68-1-114. <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/Annots[ 13 0 R] /MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Yet, the primary way to determine the differences between at-risk and reckless behavior is to carefully consider the system-based causes that might have contributed to the behavioral choices. Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. Detailed information about disciplinary . Only cases that have occurred within the most recent ten (10) years shall be disclosed by the department to the public; All medical malpractice court judgments, all medical malpractice arbitration awards in which a payment is awarded to a complaining party and all settlements of medical malpractice claims in which a payment is made to a complaining party beginning with reports for 1998 and each subsequent year; provided, such reports shall not be disseminated beyond the most recent ten-year period, but shall include the most recent ten-year period for which reports have been filed. This timeline will help, Medication Safety Officers Society (MSOS). It is not our intent to embarrass or diminish the TNBoard of Nursing by pointing out what we find disturbing or unjust in the deliberations of this complex matter, but rather to find a better way to achieve justice, learning, and improvement in safety. ); Names of medical schools or professional and training schools and dates of graduation; Graduate medical education or other graduate-level training; Specialty board certification as determined by the relevant board; Names of the hospitals where the licensee has privileges; The identification of any translating services that may be available at the licensee's primary practice location; An indication of which managed care plans in which the licensee participates; An indication of TennCare plans in which the licensee participates; Appointments to medical school faculties and indication as to whether a licensee has a responsibility for graduate medical education within the most recent ten (10) years; (optional), Information regarding publications in peer-reviewed medical literature; (optional) and, Information regarding professional or community service associations, activities and awards; (optional). More warnings would not have changed her performance.. The information on this website is for general information purposes only. In December 2017, RaDonda made a fatal medication error when administering vecuronium rather than Versed to a patient in radiology. Health Professionals Boards Disciplinary Actions, Tennessee Department of Health Publications. Disciplinary Actions by the Tennessee Board of Nursing, License revoked: LPN = 2, CNA = 5, RN = 11, License suspended: LPN = 1, CNA = 0, RN = 14, License probation: LPN = 0, CNA = 0, RN = 15, License reprimanded: LPN = 0, CNA = 0, RN = 3, 23 Drug abuse, including over-prescribing or illegal prescriptions, 02 Patient chart falsification or patient chart data recorded illegibly, 02 Drug addiction, including substance addictionor substance use on duty, 19 Incompetence, negligence or unprofessional conduct. Patients, coworkers, members of the public, or employers can call the board of nursing, put complaints in writing, or complete a board of nursing Web site complaint form. e-Notify for Institutions is a free of charge innovative nurse licensure notification system where you receive real-time notifications about nurses you employ. Suite 400 This page has information and updates on nursing boards and regulation specific to Georgia. Projectionsbased on a single month, while not statistically accurate, suggest a large number of annual nursing license disciplinary actions may result from controlled substance issues. There can be latitude in interpretation of intention and evidential proof of alleged misbehavior tovigorously defend nursing professionalsagainst the board's rulings. Nothing on this site should be taken as legal advice for any individual ISMP was shocked, discouraged, and deeply saddened to learn that the Tennessee (TN) Board of Nursing recently revoked RaDonda Vaughts professional nursing license indefinitely, fined her $3,000, and stipulated that she pay up to $60,000 in prosecution costs. For Institutions. x|83"n lNb:;U}#(jW5m?{8}q~;.>>vK}s[M^^\8_r%N){\~A9aH\9c$f#;_z5]m3g`utfpub>WdU_8WD,(Qs>qhD"63P22.3d|`zKA(%#PIA$1q?JwDU;G\-; NCSBN members utilize Nursys via nursys.org to: Receive automated license expiration reminders and status updates. The RaDonda Vaught case is confusing. In a Just Culture, inadvertent behavior (human error) is not worthy of disciplinary sanction, regardless of the outcome, and the quality of behavioral choices made during an event are thoroughly examined to determine whether there was conscious disregard of significant risks. <>/Metadata 1427 0 R/ViewerPreferences 1428 0 R>> %%EOF RaDonda could not have consciously disregarded a substantial and unjustifiable riska requirement for reckless behaviorbecause she had no idea that she had made a mistake. Below is a list of actions taken in July 2020. .`jh L@ b Without your 214 2nd Avenue N. The mission of each board is to safeguard the health, safety and welfare of . Patient involved in medication error is withdrawn from life support and dies. Listed below are the monthly summaries of disciplinary actions taken against health professionals and/or unlicensed individuals. Disciplinary Action. Nursing Disciplinary Process in Tennessee SURBER, ASHER, SURBER & MOUSHON, PLLC WWW.TENNLAWFIRM.COM (615)997-1914 6 Grounds for Disciplinary Action Rules of the Tennessee Board of Nursing describe the Standards of Nursing Conduct or Practice. endobj Below is a list of actions taken in March 2021. Please secure your User ID and Password for future use. Board actions may include: Fine or civil penalty. Suite 400, For example, in the case of suspected theft or misappropriation, were there other professionals or employees present who had access to the alleged misappropriated items? Discipline was defined as a formal action taken by a board of nursing or a court, whereby an APRN received a formal letter of reprimand, a restriction placed on an active license or certification, such as a prohibition against narcotic access, restriction from participating in the multi-state licensure compact, suspension with or without a stay, The nurse claims that she questioned the need for monitoring the patient and was told that monitoring was not required. Disputed failure. Disputed failure. If you are threatened with the loss of your professional license, you must take prompt action. To be clear, nurses cannot be held accountable for achieving the five rights; they can only be held accountable for following the processes that their organizations have designed and held out as the best way to verify the five rights. Nurse could not carry out the physicians order to repeat the first dose if insufficient because she did not monitor the effectiveness of the first dose. e-Notify for Nurses helps nurses easily manage their licenses at no cost to them. U.S. endobj But the five rights are merely broadly stated goals or desired outcomes of safe medication practices that offer no procedural guidance on how to achieve these goals. <> The Office of Consumer Right to Know is charged with seeking and collecting this information and providing it to consumers via the Departments web site. THE TENNESSEE BOARD OF NURSING CHAPTER 1000-04 ADVANCED PRACTICE NURSES AND CERTIFICATES OF FITNESS TO PRESCRIBE . Disciplinary action against her license was then filed. Also, disciplinary sanctions are not imposed for at-risk behaviors, including not following the rules; any system design failures that may have contributed to not following the rules must be examined and factored into the judgment of the behavior. Links to various Internet sites are available from the Department of Health Websitehome pageand from the Health Professional Boards Website. Also, it cannot be asserted that the failure to document in the EHR contributed to the patients harm or denied her any opportunity for recovery. Map & Directions [+]. Adapted from: Kelman B. The location of the licensee's primary practice setting; A description of any criminal convictions for felonies and, as determined by the board, serious misdemeanors, within the most recent ten (10) years. At the time of the error, the EHR, ADC software, and pharmacy computer system were not communicating properly, leading to significant pharmacy order verification delays. %PDF-1.6 % National Council of State Boards of Nursing, Inc. All Rights Reserved. Also, hospital policy did not require monitoring after Versed administration, and the drug was not mentioned in the moderate sedation policy or the hospitals high-alert medication list. Any change to information is required to be reported within 30 days of the change. The purpose of the discipline imposed is remediation; in other words, "to correct practice and promote safety". Licensure QuickConfirm is a free service that allows employers and recruiters to retrieve licensure and any applicable discipline documentation in one convenient location. Make a User ID that you can remember, such as your email address. While the Board accepted the state prosecutors recommendation to revoke RaDondas nursing license, ISMP doubts that the Boards action was just, and we believe it set us back 25 years in patient safety. endstream endobj startxref hb```@( g0A2kC.)3gZZN.qY{IU!FIP!DCA vs5 Tennessee law mandates that specific health care professionals submit information to the Department regarding details of their training, specialty certification and practice. You can read the details of the error in three of our 2019 newsletters (January 17, 2019;February 14, 2019; March 14, 2019). If it was a choice to not read the front of the label, at worse, it would be an at-risk behavior since most decisions are made on the fly in the subconscious, without the risk monitor firing. See Table 1 for a more detailed timeline of events. Filing Complaints and Researching Disciplinary Actions . % Also, healthcare practitioners, including nurses, will not want to speak up when they make an error, which will cripple learning, prevent the recognition of the need for system redesign, and set the healthcare culture back to when hiding mistakes and punitive responses to errors were the norm. Institute for Safe MedicationPractices %PDF-1.7 If you are a licensed professional and have been arrested for a crime, your license to practice may be on the line. She did not read the front of the medication label due to either a momentary distraction (error) or an unsafe practice habit (at-risk behavior). As one Board member noted, I feel like, as humans, every one of us make mistakes, none of us are perfect. 1419 0 obj <>/Filter/FlateDecode/ID[<7C1E6885F79A2840B3CD3D4380937611><607411345D04C24E89F3B328005C117C>]/Index[1406 27]/Info 1405 0 R/Length 73/Prev 82019/Root 1407 0 R/Size 1433/Type/XRef/W[1 2 1]>>stream Filing Complaints and Researching Disciplinary Actions. Contact us with any comments or questions. The prosecutor acknowledged that the hospital had various system failures that contributed to the error; however, he stressed that the Board is not here to look at the system and is instead looking at individual conduct. Thus, the Board judged RaDondas behavior in isolation of the contributing system failures. Filing a Complaint; Monthly Disciplinary Action Report; Social Media; . nunsirg ce nli es. However, RaDonda also testified that the error was made because of flawed procedures at the hospital, particularly the lack of timely communication between the pharmacy computer system and the ADC, which led to significant delays in accessing medications and the hospitals permission to temporarily override the ADC to obtain prescribed medications that were not yet linked to the patients profile in the ADC. 1406 0 obj <> endobj Contact the board at (615) 532-5166. Nurse could not know the dose of the drug she administered if she had not read the label and knew the concentration. Development of Sanctioning Guidelines for Public Discipline in Nursing Regulation: The North Carolina Board of Nursing Journey; What Could Happen: The Consequences of "Practice Drift" hb```\^ !0!U[j|}+Iv0H/\K Safe, competent nursing practice is grounded in the law as written in the state nurse practice act (NPA) and the state rules/regulations. 1 0 obj Table 2. In the end, the prosecutor made the statement that, Nothing [the hospital] could have done would have made the respondent [RaDonda] meet the standards of nursing practice She admitted to alarm and warning fatigue. Listings are sorted by the year of original Board action issued then by last name, first name. After discussions on this topic, the nurse did not think she had a duty to monitor the patient. The National Council of State Boards of Nursing (NCSBN) is a not-for-profit organization whose purpose is to provide an organization through which boards of nursing act and counsel together on matters of common interest and concern affecting the public health, safety and welfare, including the development of licensing examinations in nursing. . These laws are defined in the Nursing Practice Act (NPA). ISMP believes the TN Board of Nursings disciplinary processes and judgment of RaDondas actions during this event are NOT aligned with the tenets of a Just Culture. DISCIPLINARY ACTION REPORT . On September 27, 2019, in a stark reversal of a 2018 decision to take no licensing action against the nurse, the TN Board of Nursing filed disciplinary action against RaDonda that focused on three violations: Unprofessional conduct related to nursing practice and the five rights of medication administration, Abandoning or neglecting a patient requiring nursing care, Failure to maintain a record of interventions. July 13, 2020 Vaught's criminal trial is scheduled to begin. The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. The professions required to submit and maintain a practitioner profile questionnaire are: Tennessee Code Annotated Title 63 Chapter 51 requires the following information to be reported to the Board for dissemination to the public on practitioner profiles: http://apps.health.tn.gov/Licensure/Default.aspx, Tennessee Department of Health Publications, Licensed Registered Respiratory Therapists, Licensed Certified Respiratory Therapists. endobj RaDonda's criminal trial is scheduled to begin on . If reading the front of the medication label was the best way to confirm the drug in hand, then RaDonda failed in that regard. Board revokes the nurses professional license and fines her $3,000. Request monthly Disciplinary Action Report by e-mail. Failure to consider the significant contribution of system failures. The prosecutor repeatedly referred to achieving the five rights of medication administration as good nursing practice and stated that, Minimally competent nursing practice requires that all five rights be followed. As presented, this appears to mean that nurses have a personal responsibility to produce the outcomes of the five rights, without error and irrespective of any system performance-shaping factors. The process is also summarized in the NCSBN videoBoard of Nursing Complaint Process: Investigation to Resolution. (1) As a result, the nurse's practice will be affected in some way and the nurse must fulfill the requirements of the discipline . Read our recipe for investigating nursing boards' oversight . Receive the monthly Disciplinary Action Report bye-mail. 0 While nursing mistakes or misconduct may lead to other consequences, such as employer reprimands, terminations, civil suits, or criminal charges, nurse disciplinary action directly affects a nurse's license. To make changes to or update the Practitioner Profile, please do so via the web at:https://lars.tn.gov/datamart/mainMenu.do. In addition to suspending or revoking a nursing license, state boards of nursing may issue fines or warnings and possibly require a nurse . Nashville Tennessean. During the hearing, RaDonda was given an opportunity to testify and defend herself; however, she never shrank from admitting her mistake. Name of Board: Tennessee Board of Nursing . Information concerning paid medical malpractice claims shall be put in context by comparing an individual licensee's medical malpractice judgment awards and settlements to the experience of other providers within the same specialty. Were they monitored and by whom and for how long? The boards interpret the laws, rules and regulations to determine the appropriate standards of practice in an effort to ensure the highest degree of professional conduct. Once enrolled, a nurse will get automatic notifications about license status, license expiration, license renewal or publicly available disciplinary actions or alerts. RaDondas criminal trial is scheduled to begin on March 21, 2022. Detailed information about disciplinary actions is available on . Investigation of the event did not include examination of recent sedation for claustrophobic patients in radiology or sedation with IV Versed to determine whether monitoring had occurred previously. Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. TDH Newsroom. Late in 2018, the hospital was investigated by the Centers for Medicare & Medicaid Services (CMS) after an anonymous whistleblower came forward to report the fatal error. Hospital settles with patients family, requiring them to not speak about the error publicly. The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. As a primary source equivalent the data is provided directly from the boards of nursing. WHEN Melissa Welsh*, a certified nurse assistant (CNA), renewed her CNA certificate, she self-reported her arrest and conviction for delivery of cocaine. The status and any disciplinary documents for individual nurses or nursing assistants licensed in Oregon are available on the OSBN Verification System . endstream endobj 1407 0 obj <. Please click the link below to access the licensure renewal page. The nurse believed she administered the prescribed dose of 1 mg (which was actually vecuronium, not Versed) after reading the directions for reconstitution on the label, correctly reconstituting the drug, and administering 1 mL of the reconstituted drug. Click here to go to the live stream site. The nurse was surprised that the medication was a powder, so she turned the vial over quickly to look at the reconstitution directions on the back of the label, without looking at the front of the label (and product name). ~\W3o3Vq~;?+|_y[OFCP"!$"1 fNr]E Xxo?_OxW/$w;~p.)}(z!% mR:muv P" NT/T*?UlaP=:> 3paRh ZC! According to the prosecutor, the Board has a policy that differentiates between human error, at-risk behavior, reckless behavior, and bad intent. (2) In order to be issued a certificate of fitness as a nurse practitioner with . However, was the Boards action fair and just in this situation? The nurse was distracted (talking to an orientee) while preparing the medication and failed to read the full medication label. Together the NPA and rules/regulations guide and govern nursing practice. Nurse did not verify that the proper medication was removed from the ADC. 63-7-115. If allegations against a nurse are proven, or he or she admits to the allegations, a board of nursing has the authority to discipline the nurse. If you applied for initial license online, you can use the same account to renew your license. Nursys is the only national nurse licensure and disciplinary database. "9$3. Nurses alleged failures and unanswered questions about the event. Place: Electronic Meeting / Poplar Room . 1432 0 obj <>stream The nurse questioned the need to monitor the patient, which was framed around the need to bring monitoring equipment along for use in radiology. Nor did anyone consider if the nurse recognized the risk associated with talking to the orientee while pulling medications from the ADC at the time of the error. DISCIPLINARY ACTION REPORT NASHVILLE, Tenn. -- Tennessee Code Annotated, Section 68-1-114 requires the Tennessee Department of Health to issue a monthly media release listing all disciplinary actions taken by the health-related boards during the prior month. News Releases; Calendar of Events; Health Advisories; TDH History Milestones; Tennessee Department of Health . Nurse License Verification service enables nurses to verify their license(s) from a Nursys verification participating board when applying for endorsement into another state. And while RaDonda made a conscious decision to not monitor the patient or scan the medications barcode, she was told that monitoring was not required, and barcode scanning technology was not available in radiology. Each provider licensing board shall set by rule adopted pursuant to the Uniform Administrative Procedures Act, compiled in title 4, chapter 5, a threshold amount below which judgments or settlements shall not be reportable; provided, such threshold shall, for chapter 6 or 9 of this title licensees, be set at seventy-five thousand dollars ($75,000), for doctors of chiropractic, regulated pursuant to chapter 4 of this title, be set at fifty thousand dollars ($50,000), for dentists, regulated pursuant to chapter 5 of this title, be set at twenty-five thousand dollars ($25,000), and for all other licensees under this title be set at ten thousand dollars ($10,000). Speak with an attorney as soon as possible. Every state and territory in the US set laws to govern the practice of nursing. Furthermore, we recognize how difficult it is to be conferred with the responsibility of protecting the public. The Administrative Procedures Division is the administrative court for the State. To cite another example, the prosecutor stated that a reasonable nurse would have seen that the ADC defaulted to searching by the generic drug name, not the brand name (which was difficult to notice at the time), rather than recognizing that the capability of the ADC to simultaneously search by brand and generic names would have been so much more effective. And mistakes have consequencesbut apparently not for those lucky enough to avoid patient harm. Nashville, An outcome bias often results in over-reacting to a singular event with unwarranted disciplinary action, or under-reacting to a system design flaw if the outcome is not harmful. Nurses disciplinary licensing hearing is held. To SEARCH and find an individual, press Control and 'f' keys, and type in name. The Board of Nursing meets 12 times a year and takes disciplinary actions during each meeting. Disciplinary hearings are conducted in accordance with the "Open Meetings Act" NMSA 1978, Chapter 10, Article 15 and all disciplinary actions are listed on the Board website and published in the Board newsletter quarterly. Information Required to be Reported on Practitioner Profiles. Nursysis the only national database for verification of nurse licensure, discipline and practice privileges for RNs,LPN/VNs and APRNs licensed in participating jurisdictions, including all states in theNurse Licensure Compact (NLC). These are all common symptoms of the deeply personal, social, spiritual, and professional crisis experienced by second victims of fatal errors. You must have JavaScript enabled to use this form. Disciplinary Action Report Page 1 of 11 . Below is a list of actions taken in NOVEMBER 2021. Nurses disciplinary hearing is scheduled but delayed due to the pandemic. Tennessee Department of Health Publications. C. omplaints to nursing boards can come from . Nurse did not verify that the proper medication was administered to the patient.

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